Hybrid Reconstruction of the Upper Lip Following Major Cancer Resections
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ISSN: 2577 - 8005 Short Communication Medical & Clinical Research Hybrid Reconstruction of the Upper Lip Following Major Cancer Resections *Corresponding author Dr. Badr M I Abdulrauf, Program Director, Plastic and Reconstructive Surgery, Department of Surgery, King Faisal Specialist Hospital and Badr M I Abdulrauf FRCSC Research Center Jeddah, Saudi Arabia Section of Plastic Surgery, Department of Surgery, King Faisal Specialist Hospital and Research Center Jeddah, Saudi Arabia Submitted:12 July 2020; Accepted: 18 July 2020; Published: 01 Aug 2020 Abstract Major defects of the Upper lip due to cancer surgery are relatively less common compared to Lower lip. Standard techniques such as Karapandzic’s are capable of reconstructing up to fifty percent of the lip otherwise, microstomia and oral incompetence may result. The Upper lip has few aesthetic characteristic details due to the philtrum, its columns and cupid’s bows. Here we are proposing incorporation of an Abbe Flap to reconstruct the central unit of Upper lip, associated with Karapandzik flaps from both sides. Use of a Lip sharing concept has an additional advantage of producing harmony to the reconstructed region, and avoidance of crowding phenomena to the Lower lip. Keywords: Upper Lip; Cancer; Reconstruction; Large Defect; lip tumor was carried out by a colleague Head and Neck surgeon, Major; Total; Subtotal; Karapandzic Flap; Abbe Flap; Combined. guided with frozen sections. “When you are short of tissues, remove some more! “ Case 1: (Figure 1a) was a 55 years old woman diagnosed with Adenocarcinoma. Preoperative inter commissure distance was 4.5 Introduction cm. A segment of 3.8 cm or over 80% full thickness of the central Lip functions include maintaining oral competence, speech, and Upper lip was resected. communication. These tasks specifically oral continence has been studied objectively and thoroughly [1]. Reconstructing the lip is considered best with local and regional tissues since it follows “Like with like” basic principle of reconstruction. Well established techniques such as Bilateral Karapandzik’s (K) rotational flaps or Johanson’s step-plasty are capable of effectively reconstructing up to fifty percent of lip tissue otherwise microstomia would result. Dieffenbach’s bilateral advancement flaps from the cheek physically would reconstruct a bigger than fifty percent defect but lip would lose its mobility and sensation [2]. In this paper, the Hybrid concept of combining K flaps with an Abbe flap is demonstrated in 2 patients with Upper lip sub-total defects. Technique: Both cases shown in this article had their oncologic management addressed by the Head and Neck oncology Figure 1a: Case 1 Subtotal full thickness Upper lip defect post multidisciplinary tumor board team. Surgical resection part of the resection of Adenocarcinoma. Med Clin Res, 2020 www.medclinres.org Volume 5 | Issue 7 | 130 Figure 2(a-c): Artist’s depiction for the reconstructive plan and steps shown in figure 1. Figure 1b: Reconstructive plan has been marked including an Abbe flap, bilateral K flaps and peri alar crescentic excisions. (A) Figure 1c: As a first step, Abbe flap has been dissected, raised from lower lip and donor site is closed. (B) Figure 1d: End of 1st stage reconstruction, where Abbe flap been flipped to replace philtrum, and K flaps have been raised and rotated bilaterally in addition to the peri-alar crescentic full thickness skin excisions to facilitate rotation. A Burrow’s triangle excision was considered unilaterally, on the left cheek. All flaps have been inset (C) together in place, they are nicely perfused. Med Clin Res, 2020 www.medclinres.org Volume 5 | Issue 7 | 131 Figure 3: Case 1 results 2 years post reconstruction and Case 2: (Figure 4a) was a 70 years old woman was diagnosed radiotherapy, with Squamous cell carcinoma (SCC). Baseline inter commissure distance was 5.0 cm. She had 3.5 cm or a 70 % full thickness of her Upper lip resected. Similar plan and surgical steps were carried out in both cases Figure 1 (b-d); Figure 2 (a-c) and Figure 4 (b-e). The width of Abbe flap was determined keeping in mind expected remaining defect after K flaps been rotated, since it is known that bilateral K flaps would reconstruct close to fifty percent of lip defect. A. At rest Figure 4a: Case 2 Post SCC resection of Upper lip with 70% full thickness defect. B. Smiling Figure 4b: Plan is marked for the Hybrid technique. C. Oral competence. Med Clin Res, 2020 www.medclinres.org Volume 5 | Issue 7 | 132 Raising the Abbe flap was done at first and its donor site closed. Upon raising the K flaps, extra care was taken on the side which Abbe flap’s pedicle was based upon. Peri- alar crescentic full thickness skin excisions were also carried out to aid in mobilizing the K flaps. All 3 flaps were brought together and repaired in layers. Flaps remained healthy. Abbe flap division and adjustment was considered in about 3 weeks. Both cases done received postoperative radiation, however done extremely well functionally. The Abbe flap provided a reasonable aesthetic replacement to the philtrum unit (Figure 3a-c) and (Figure 5a, b). Figure 4c: K flaps and Abbe flap have been dissected and raised. Figure 5a: Result 6 months postop, at rest. Figure 4d: Artist’s depiction of flaps been raised. Figure 5b: Mouth opening ability. Discussion All local reconstructive techniques depend on skin laxity and fortunately lack of elasticity. There are more techniques of lip reconstruction for cancer that are applicable to Lower lip, since it is more commonly affected and hence more commonly been Figure 4e: Completion of reconstruction and all flaps been inset. reconstructed and studied [2, 3]. Cleft lip surgery is an exception Med Clin Res, 2020 www.medclinres.org Volume 5 | Issue 7 | 133 and a very specific kind of congenital anomaly. Ethical Statement Theoretically speaking many techniques can be applied to both Funding: This work did not require any funding. lips. However, excellent techniques such as Johanson’s Step-plasty are not applicable to Upper lip due to obvious reason of distorting Conflict of Interest: As an author, we declare there is no conflict aesthetic units otherwise. of interest. Many free tissue transfer techniques including Radial forearm flap with palmaris longus, have been described and evolved for major Ethical Approval: Procedures performed in the case series were in lip defects, and are considered as viable options for some surgeons accordance with the ethical standards of the institutional research [3-5]. But these carry the disadvantages of being barely a physical committee as well as in accordance with the revised Helsinki barrier with poor sensation, texture mismatch and the inability to Declaration 2013. The work presented is a modification of surgical replace a vermilion like tissue [5]. techniques as per the need of particular case. We have already introduced the “Hybrid concept” of reconstruction Informed Consent: Informed consent was obtained from all in Lower lip major defects, using various combinations of flaps patients undergoing the procedure, after discussing the potential [6]. Uglesic et al., Gonzalez and Etchichury have also shared their risks and benefits. experience of the Lower lip large defects being reconstructed with different techniques [7, 8]. Here we are demonstrating similar Acknowledgment: None. concept of combining a variety of maneuvers in cases of the Upper lip major defects. References 1. Stranc MF, Fogel ML (1984) Lip function: A study of oral The percentage of a lip defect post resection is estimated based on continence. BJPS 37: 550-557. the baseline inter commissure distance, since it is variable from one 2. Stranc MF (1994) Reconstruction of the lips. In: Mimis Cohen individual to another [9]. The two cases shown in this article, both (ed) Mastery of plastic and Reconstructive surgery, 1st edition. had significant defect especially case 1, where approximately 80% Little Brown co. of the Upper lip was removed (commissures preserved). 3. Neligan PC (2009) Strategies in lip reconstruction. Clinics in Plastic Surgery 36: 477-485. The idea of incorporating Abbe flap obviously came for the purpose 4. Sasaki K, Sasaki M, Oshima J, Aihara Y, Nishijima A (2019) of filling part of the large defect. But it was noted during surgery, Flap reconstruction for full thickness oral defects involving the taking that shield shape flap from the lower lip worked more so like oral commissure combined with oral modiolus reconstruction the concept of Burrow’s triangle, helping in closure. When bilateral using a facial sling. Microsurgery. K flaps are used for closure of a defect, it is a common observation 5. Vansison C, Beckmann N, Smith A (2019) Recent advances in one would notice the opposing lip is somewhat crowded. Taking an lip reconstruction. Current opinion otolaryngology Head and Abbe flap makes all the sense, hence the fraise: neck surgery journal 27: 219-226. 6. Abdulrauf BMI (2020) The Hybrid concept in lip “When you are short of tissues, remove some more”. reconstruction. Int J of Otorhinolaryngology and Head and Neck Surgery 6: 1183-1187. Technically, Raising the Abbe flap was done initially and under 7. Uglesic V, Amin K, Dedliol E, Koustic D (2019) Combined loupe magnification. Abbe flap requires more tedious dissection Karapandzik-Abbe/Estlande/Stein flap for subtotal and total and learning curve compared to other regional flaps; it makes more lower lip reconstruction. Journal of Plastic Reconstructive sense to do that part first. Furthermore, we tend to avoid using Aesthetic Surgery 72: 484-490. adrenaline infiltration whenever doing an Abbe flap. 8. Gonzalez A, Etchichury D (2018) Reconstruction of large defects of the lower lip after Mohs surgery: The use of We believe the Hybrid concept of Upper lip reconstruction has combined Karapandzik and Abbe flaps. Annals of Plastic the potential to provide optimum results both functionally and Surgery 81: 433-437.